Blue Cross Blue Shield of North Dakota (BCBSND) regularly develops and revises pharmacy policies in response to rapidly changing pharmaceutical requirements. Our commitment is to update the provider community as policies are adopted and/or revised. Benefit determinations are made based on the policy in effect at the time of service.
The following pharmacy policies were reviewed by the Internal Medical Policy Committee on Sept. 21, 2021, and will be updated within the next 30-45 days on our website.
Pharmacy Policies
The following medical drug policies are new and require precertification effective 10/1/2021:
The following medical drug policy is new effective 10/1/2021:
The following medical drug policy will require precertification effective 11/1/2021:
The following medical drug policies were revised:
- Ado-trastuzumab emtansine (Kadcyla)
- Bevacizumab (Avastin) and Bevacizumab Biosimilars
- Blinatumomab (Blincyto)
- Chimeric Antigen Receptor Therapy for Leukemia and Lymphoma
- Immune Globulin Therapy
- Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
- Inhalation Products for the Management of Cystic Fibrosis
- Isatuximab-irfc (Sarclisa)
- Portable External Infusion Pump
- Programmed Death Receptor (PD-1)/ Programmed Death-Ligand (PD-L1) Blocking Antibodies
- Rituximab (Rituxan), Rituximab Biosimilars, and Rituximab and Hyaluronidase Human (Rituxan Hycela)
- Ziv-aflibercept (Zaltrap)
The following medical drug policies had coding changes effective 10/1/2021:
- Casimersen (Amondys-45)
- Certolizumab (Cimzia)
- Chemodenervation with Botulinum Toxin
- Chimeric Antigen Receptor Therapy for Multiple Myeloma
- Contraceptive Management
- Evinacumab-dgnb (Evkeeza)
- Fulvestrant (Faslodex)
- Gonadotropin Releasing Hormones (GnRHs) Analogs
- Melphalan Flufenamide (Pepaxto)
- Oncologic Indications for Histone Deacetylase (HDAC) Inhibitors
- Plerixafor (Mozobil)
- Tocilizumab (Actemra)
- Trilaciclib (Cosela)
The following medical drug policies were reviewed with no clinical content change:
- Belatacept (Nulojix)
- Copanlisib (Aliqopa)
- Daunorubicin and Cytarabine Liposomal (Vyxeos)
- Hydroxyprogesterone Caproate Injection as a Technique to Reduce Preterm Birth in High-Risk Pregnancies
- Intravenous Anesthetics for Off-Label Indications
- Luspatercept (Reblozyl)
- Mogamulizumab-kpkc (Poteligeo)
- Necitumumab (Portrazza)
- Olaratumab (Lartruvo)
- Pegloticase (Krystexxa)
- Polatuzumab vedotin-piiq (Polivy)
- Romiplostim (Nplate)
- Trastuzumab (Herceptin), Trastuzumab Biosimilars, and Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
- Treatment of Gaucher Disease
- Vestronidase Alfa-vjbk (Mepsevii)
The following new Utilization Management program was effective on the NetResults Formulary 9/1/2021:
- Verquvo Prior Authorization/Quantity Limit Program